Percutaneous Coronary Intervention Strategy Research Articles

Complete vs Culprit-Lesion-Only Revascularization for ST-Segment Elevation Myocardial Infarction

Recently, the Complete vs Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI (percutaneous coronary intervention) for STEMI (ST-segment elevation myocardial infarction [MI]) (COMPLETE) trial showed that angiography-guided PCI of the nonculprit lesion with the goal of complete revascularization reduced cardiovascular (CV) death or new MI compared with PCI of the culprit lesion only in STEMI. Whether complete revascularization also reduces CV mortality is uncertain. Moreover, whether the association of complete revascularization with hard clinical outcomes is consistent when fractional flow reserve (FFR)- and angiography-guided strategies are used is unknown. To determine through a systematic review and meta-analysis (1) whether complete revascularization is associated with decreased CV mortality and (2) whether heterogeneity in the association occurs when FFR- and angiography-guided PCI strategies for nonculprit lesions are performed. A systematic search of MEDLINE, Embase, ISI Web of Science, and CENTRAL (Cochrane Central Register of Controlled Trials) from database inception to September 30, 2019, was performed. Conference proceedings were also reviewed from January 1, 2002, to September 30, 2019. English-language randomized clinical trials comparing complete revascularization vs culprit-lesion-only PCI in patients with STEMI and multivessel disease were included. The combined odds ratio (OR) was calculated with the random-effects model using the Mantel-Haenszel method (sensitivity with fixed-effects model). Heterogeneity was measured using the I2 statistic. Publication bias was evaluated using the inverted funnel plot approach. Data were analyzed from October 2019 to January 2020. Cardiovascular death and the composite of CV death or new MI. Ten randomized clinical trials involving 7030 unique patients were included. The weighted mean follow-up time was 29.5 months. Complete revascularization was associated with reduced CV death compared with culprit-lesion-only PCI (80 of 3191 [2.5%] vs 106 of 3406 [3.1%]; OR, 0.69 [95% CI, 0.48-0.99]; P = .05; fixed-effects model OR, 0.74 [95% CI, 0.55-0.99]; P = .04). All-cause mortality occurred in 153 of 3426 patients (4.5%) in the complete revascularization group vs 177 of 3604 (4.9%) in the culprit-lesion-only group (OR, 0.84 [95% CI, 0.67-1.05]; P = .13; I2 = 0%). Complete revascularization was associated with a reduced composite of CV death or new MI (192 of 2616 [7.3%] vs 266 of 2586 [10.3%]; OR, 0.69 [95% CI, 0.55-0.87]; P = .001; fixed-effects model OR, 0.69 [95% CI, 0.57-0.84]; P < .001), with no heterogeneity in this outcome when complete revascularization was performed using an FFR-guided strategy (OR, 0.78 [95% CI, 0.43-1.44]) or an angiography-guided strategy (OR, 0.61 [95% CI, 0.38-0.97]; P = .52 for interaction). In patients with STEMI and multivessel disease, complete revascularization was associated with a reduction in CV mortality compared with culprit-lesion-only PCI. There was no differential association with treatment between FFR- and angiography-guided strategies on major CV outcomes.

Prognostic importance of culprit lesion location in cardiogenic shock due to myocardial infarction.

As existing results are diverging, and the patient population has changed significantly, this study sought to investigate the prognostic importance of the culprit lesion location in patients with cardiogenic shock due to myocardial infarction (AMICS), in a contemporary and unselected patient population. From the recruitment area of two tertiary heart centres in Denmark, covering 3.9 million citizens corresponding to two-thirds of the Danish population, all AMICS patients in the period of 2010-2017 were individually identified and validated through patient records. A total of 1716 patients with AMICS were identified. Immediate revascularization was performed in 1482 patients (86%). Among these, a culprit lesion in the left main coronary artery (LM) was associated with the highest 30-day mortality rate (66%), plogrank<0.0001, which persisted after multivariable adjustment for variables known to be associated with mortality in AMICS, including age, gender, heart rate, lactate, diabetes, stroke and out-of-hospital cardiac arrest, p=0.002. A culprit lesion in the remaining coronary arteries had comparable and lower 30-day mortality (43-48%), plogrank=0.39. Patients with multivessel disease had comparable prognoses irrespective of whether a culprit-only or multivessel percutaneous coronary intervention strategy was used (plogrank=0.80), and whether partial or complete revascularization was achieved (plogrank=0.24). Among AMICS patients undergoing revascularization, a LM culprit lesion was associated with the highest short-term mortality, whereas patients with a culprit lesion in the remaining coronary arteries had comparable and lower mortality rates. Multivessel disease patients had similar prognoses irrespective of percutaneous coronary intervention approach and whether partial or complete revascularization was achieved.

The comparison of procedural and clinical outcomes of thrombolytic-facilitated and primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction (STEMI): Findings from PROVE/ACS study.

BACKGROUNDThere is still a controversy in the preferred method of reperfusion in acute ST-segment elevation myocardial infarction (STEMI), when the achievement of well-defined "golden time" is difficult. We sought to evaluate the procedural and in-hospital outcomes of the strategy of "thrombolytic administration and rescue or routine percutaneous coronary intervention (PCI)" versus "primary PCI (PPCI)" strategy in acute STEMI.METHODSIn this observational prospective study, the data of 237 patients with acute STEMI presented or referred to Chamran Cardiovascular Research Center in Isfahan, Iran, were collected (PROVE/ACS study). Baseline characteristics, thrombolysis in myocardial infarction (TIMI) flow grade of infarct-related artery (IRA), left ventricular ejection fraction (LVEF), and in-hospital outcomes were evaluated.RESULTSThe mean age of patients was 61.4 ± 13.0 years, 86.9% were men, 13.1% were diabetic, and 67.9% had anterior STEMI. Patients in the "thrombolytic then PCI" group were younger, more smoker, more often male with higher body weight and lower systolic blood pressure (SBP). The pre-PCI TIMI flow grade 3 was more often seen in the "thrombolytic then PCI" group (39.4% vs. 21.0%, P < 0.001) and less thrombectomy was performed in this group of patients (12.9% vs. 26.7%, P = 0.011). Time to reperfusion was significantly longer in PPCI group (182.4 ± 233.7 minutes vs. 44.6 ± 93.4 minutes, respectively, P < 0.001). No difference in mortality, mean of LVEF, and incidence of atrial fibrillation (AF) was observed in two groups.CONCLUSIONIf the PPCI strategy could not be performed in the golden time, the strategy of thrombolytic administration and rescue or routine PCI leads to more initial IRA patency and less thrombectomy with similar clinical outcomes.

Prognostic Value of SYNTAX Score in Patients With Infarct-Related Cardiogenic Shock: Insights From the CULPRIT-SHOCK Trial

ObjectivesThis study sought to evaluate the prognostic value of the SYNTAX (SYNergy between PCI with TAXUS and Cardiac Surgery) scores in patients undergoing percutaneous coronary intervention (PCI) for multivessel coronary disease with infarct-related cardiogenic shock (CS). BackgroundThe prognostic value of the SYNTAX score in this high-risk setting remains unclear. MethodsThe CULPRIT-SHOCK (Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock) trial was an international, open-label trial, where patients presenting with infarct-related CS and multivessel disease were randomized to a culprit-lesion-only or an immediate multivessel PCI strategy. Baseline SYNTAX score was assessed by a central core laboratory and categorized as low SYNTAX score (SS ≤22), intermediate SYNTAX score (22<SS≤32) and high SYNTAX score (SS>32). Adjudicated endpoints of interest were the 30-day risk of death or renal replacement therapy (RRT) and 1-year death. Associations between baseline SYNTAX score and outcomes were assessed using multivariate logistic regression. ResultsPre-PCI SYNTAX score was available in 624 patients, of whom 263 (42.1%), 207 (33.2%) and 154 (24.7%) presented with low, intermediate and high SYNTAX score, respectively. A stepwise increase in the incidence of adverse events was observed from low to intermediate and high SYNTAX score for the 30-day risk of death or RRT and the 1-year risk of death (p < 0.001, for all). After multiple adjustments, intermediate and high SYNTAX score remained strongly associated with 30-day risk of death or renal replacement therapy and 1-year risk of all-cause death. There was no significant interaction between SYNTAX score and the coronary revascularization strategy for any outcomes. ConclusionsIn patients presenting with multivessel disease and infarct-related CS, the SYNTAX score was strongly associated with 30-day death or RRT and 1-year mortality.

Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Cardiogenic Shock

ObjectivesThis study sought to compare outcomes of patients enrolled in the NCSI (National Cardiogenic Shock Initiative) trial who were treated using a revascularization strategy of percutaneous coronary intervention (PCI) of multivessel PCI (MV-PCI) versus culprit-vessel PCI (CV-PCI). BackgroundIn patients with multivessel disease who present with acute myocardial infarction and cardiogenic shock (AMICS), intervening on the nonculprit vessel is controversial. There are conflicting published reports and lack of evidence, particularly in patients treated with early mechanical circulatory support (MCS). MethodsFrom July 2016 to December 2019, patients who presented with AMICS to 57 participating hospitals were included in this analysis. All patients were treated using a standard shock protocol emphasizing early MCS, revascularization, and invasive hemodynamic monitoring. Patients with multivessel coronary artery disease (MVCAD) were analyzed according to whether CV-PCI or MV-PCI was undertaken during the index procedure. ResultsOf 198 patients with MVCAD, 126 underwent MV-PCI (64%) and 72 underwent CV-PCI (36%). Demographics between the cohorts were similar with respect to age, sex, history of diabetes, prior PCI or coronary artery bypass grafting, and prior history of myocardial infarction. Patients who underwent MV-PCI had a trend toward more severe impairment of cardiac output and worse lactate clearance on presentation, and cardiac performance was significantly worse at 12 h. However, 24 h from PCI, the hemometabolic derangements were similar. Survival and rates of acute kidney injury were not significantly different between groups (69.8% MV-PCI vs. 65.3% CV-PCI; p = 0.51; and 29.9% vs. 34.2%; p = 0.64, respectively). ConclusionsIn patients with MVCAD presenting with AMICS treated with early MCS, revascularization of nonculprit lesions was associated with similar hospital survival and acute kidney injury when compared with culprit-only PCI. Selective nonculprit PCI can be safety performed in AMICS in patients supported with mechanical circulatory support.

Coronary artery disease management and cost implications with fractional flow reserve guided coronary intervention in Indian patients with stable ischemic coronary artery disease.

To study the safety of stent avoidance, frequency of change in management decisions, and its cost implications while using a fractional flow reserve (FFR)-guided treatment strategy for intermediate-grade coronary artery stenosis. The impact of FFR in guiding management decisions and its cost implications has not been studied after imposition of a ceiling on stent prices by the Government of India. In 400 patients with 477 intermediate-grade coronary lesions for whom coronary intervention was planned, functional assessment using FFR was done. Incidence of the primary composite endpoint (major adverse cardiac event [MACE], cardiac death, myocardial infarction, objective evidence of ischemia, and target vessel revascularization) in the stent avoided subset was compared with the stented group at follow-up. Micro-costing analysis was done using a computed model with current stent and FFR wire prices. The overall incidence of MACE was 4.9%, 0.9% in the stent-avoided subset and 6.9% in stented group (p = 0.04, comparing the latter two) at a median follow-up of 21 months (interquartile range 12-31 months). Serious adverse events occurred only in 1% of patients receiving adenosine. The average cost saving was Indian rupees (INR) 51,847 [United States Dollar (USD) 746] per patient, resulting in total savings of INR 15,813,379 (USD 227,530). Cost savings persisted but were lower by 36% (INR 18,613/USD 268 per patient) after the ceiling of stent prices. FFR-guided percutaneous coronary intervention (PCI) strategy is safe and cost-effective in countries where majority of patients self-finance their health care, resulting in stent and PCI avoidance in approximately one in three patients referred for coronary angioplasty.

Improving Outcomes With IVUS Guidance During Percutaneous Coronary Interventions

This review highlights the evidence surrounding the adjunctive diagnostic and therapeutic benefits of intravascular ultrasound (IVUS) during percutaneous coronary intervention (PCI). Meta-analyses of randomized trials demonstrate that IVUS has a major impact on PCI-related outcomes with drug-eluting stents by reducing cardiovascular mortality and repeat revascularization. Its application in calcific coronary artery disease has helped identify the benefits and safety of coronary atherectomy, along with playing an important role for primarily guiding PCI while significantly reducing contrast volume in individuals with renal dysfunction. IVUS applications have been extended to the realms of CTO intervention, aneurysmal coronary disease, and iatrogenic/spontaneous coronary artery dissection. IVUS is also a proven cost-effective strategy. Nevertheless, despite these benefits, the global uptake of IVUS-guided PCI remains low. IVUS plays a pivotal role during PCI, particularly complex calcific and long lesions. IVUS-guided PCI is safe, cost-effective, and associates with substantial reductions in MACE. However, the worldwide uptake of IVUS-guided PCI remains considerably low. Further efforts are required to promote this evidence-based PCI strategy among the global interventional cardiology community to further improve the outcomes of our PCI candidates.

Quantitative flow ratio–guided strategy versus angiography-guided strategy for percutaneous coronary intervention: Rationale and design of the FAVOR III China trial

Quantitative flow ratio (QFR) is a novel angiography-based approach enabling fast computation of fractional flow reserve without use of pressure wire or adenosine. The objective of this investigator-initiated, multicenter, patient- and clinical assessor-blinded randomized trial is to evaluate the efficacy and cost-effectiveness of a QFR-augmented angiography-guided (QFR-guided) strategy versus an angiography-only guided (angiography-guided) strategy for percutaneous coronary intervention (PCI) in patients with coronary artery disease. Approximately 3,830 patients will be randomized in a 1:1 ratio to a QFR-guided or an angiography-guided strategy. Included subjects scheduled for coronary angiography have at least 1 lesion eligible for PCI with 50%-90% stenosis in an artery with ≥2.5 mm reference diameter. Subjects assigned to the QFR-guided strategy will have QFR measured in each interrogated vessel and undergo PCI when QFR ≤0.80, with deferral for lesions with QFR >0.80. Those assigned to the angiography-guided strategy will undergo PCI based on angiography. Optimal medical therapy will be administered to all treated and deferred patients. The primary end point is the 1-year rate of major adverse cardiac events (MACE), a composite of all-cause mortality, any myocardial infarction, or any ischemia-driven revascularization. The major secondary end point is 1-year MACE excluding periprocedural myocardial infarction. Other secondary end points include the individual components of MACE and cost-effectiveness end points. The sample size affords 85% power to demonstrate superiority of QFR guidance compared with angiography guidance. The FAVOR III China study will be the first randomized trial to examine the effectiveness and cost-effectiveness of a QFR-guided versus an angiography-guided PCI strategy in coronary artery disease patients.

Diagnostic performance of a vessel-length-based method to compute the instantaneous wave-free ratio in coronary arteries

The instantaneous wave-free ratio (iFR) is a recently introduced vasodilator-free index to assess the functional severity of coronary stenosis in the resting state, while fractional flow reserve (FFR) is the gold standard index in hyperemia. The computed instantaneous wave-free ratio (CT-iFR) is a noninvasive method to estimate iFR using computer simulations. Here, we developed a vessel-length-based CT-iFR method in patient-specific models of coronary arteries. This method was implemented by coupling a three-dimensional computational fluid dynamics model with a lumped parameter model (LPM) of coronary circulation in a non-hyperemic resting state. A time-varying resistance in the LPM was used for the iFR simulation. In total, 50 coronary vessels of 32 patients were computed, and their CT-iFR values were compared with clinically measured iFRs to evaluate the diagnostic performance of the present CT-iFR method. The area under the receiver operating characteristics curve of CT-iFR validation was 0.93. In diagnostic performances of CT-iFR, accuracy, sensitivity, and specificity were 86%, 83.3%, and 86.8%, respectively. These results indicate that this CT-iFR method can be used as a pre-operative aid to establish a percutaneous coronary intervention strategy as a noninvasive alternative to iFR.

Management of multivessel coronary artery disease in patients with non-ST-elevation myocardial infarction: a complex path to precision medicine.

Recent analyses suggest the incidence of acute coronary syndrome is declining in high- and middle-income countries. Despite this, overall rates of non-ST-elevation myocardial infarction (NSTEMI) continue to rise. Furthermore, NSTEMI is a greater contributor to mortality after hospital discharge than ST-elevation myocardial infarction (STEMI). Patients with NSTEMI are often older, comorbid and have a high likelihood of multivessel coronary artery disease (MVD), which is associated with worse clinical outcomes. Currently, optimal treatment strategies for MVD in NSTEMI are less well established than for STEMI or stable coronary artery disease. Specifically, in relation to percutaneous coronary intervention (PCI) there is a paucity of randomized, prospective data comparing multivessel and culprit lesion-only PCI. Given the heterogeneous pathological basis for NSTEMI with MVD, an approach of complete revascularization may not be appropriate or necessary in all patients. Recognizing this, this review summarizes the limited evidence base for the interventional management of non-culprit disease in NSTEMI by comparing culprit-only and multivessel PCI strategies. We then explore how a personalized, precise approach to investigation, therapy and follow up may be achieved based on patient-, disease- and lesion-specific factors.

A Novel Algorithm for Treating Chronic Total Coronary Artery Occlusion

BackgroundGuidewire manipulation time is rarely used in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) strategies. ObjectivesThis study sought to develop an algorithm based on angiographic characteristics and guidewire manipulation time. MethodsThis study assessed 5,843 patients undergoing CTO PCI between January 2014 and December 2017 and enrolled in the Japanese CTO-PCI expert registry and analyzed their CTO-PCI strategies, procedural outcomes, and guidewire manipulation time. ResultsPrimary retrograde approach was performed on 1,562 patients. The average Japanese CTO score of primary antegrade approach and primary retrograde approach were 1.7 ± 1.1 and 2.3 ± 1.1, respectively (p < 0.001). The overall guidewire and technical success rates were 92.8% and 90.6%, respectively. Median guidewire manipulation time of guidewire success and failure were 56 min (interquartile range [IQR]: 22 to 111 min) and 176 min (IQR: 130 to 229 min), respectively. Median successful guidewire crossing time of single wiring and parallel wiring in the antegrade alone were 23 min (IQR: 11 to 44 min) and 60 min (IQR: 36 to 97 min), and rescue retrograde approach and primary retrograde approach were 126 min (IQR: 87 to 174 min) and 107 min (IQR: 70 to 161 min), respectively (p < 0.001). Significant predictors for antegrade guidewire failure in primary antegrade approach, which were reattempt, CTO length of ≥20 mm, and no stump, did not predict guidewire failure after collateral channel crossing in primary retrograde approach. ConclusionsResults from a large registry with information on guidewire manipulation time as well as CTO characteristics suggest a redefinition of the current strategy algorithms.

Very Late Stent Thrombosis in Drug-Eluting Stents New Observations and Clinical Implications.

Despite the reduction in stent failure with newer-generation drug-eluting stents, very late stent thrombosis (VLST) remains an unpredictable and potentially catastrophic complication of coronary revascularization procedures and is associated with high morbidity and mortality. Here, we present an updated overview of the latest advances in understanding the causes of VLST. Clinical studies that revealed potential risk factors and pathophysiologic studies on the mechanisms of VLST are discussed. Importantly, novel insights from recent advances in intravascular imaging are included. To date, there is no clinical guideline for VLST treatment. We propose an evidence-based recommendation that an intravascular-imaging-informed percutaneous coronary intervention strategy combined with optimized antiplatelet therapy is the foundation for successful VLST clinical management. Moreover, the future of VLST prevention, such as improved patient risk stratification and advances in addressing late stent failure, are also discussed.

P6419Machine learning in critical care: the role of diabetes and age in acute coronary syndromes

Abstract Background Patients with diabetes and non-ST elevation acute coronary syndrome (NSTE-ACS) have an increased risk of mortality and adverse outcomes following percutaneous coronary intervention (PCI). Purpose We aimed to investigate the impact of early, within 24 hours PCI compared with only routine medical treatment on clinical outcomes in a large international cohort of patients with NSTE-ACS and diabetes. Methods We identified 1,250 patients with diabetes and NSTE-ACS from a registry-based population between October 2010 and April 2016. The primary endpoint was 30-day all-cause mortality. The secondary endpoint was the composite outcome of 30-day all-cause mortality and left ventricular dysfunction (ejection fraction &lt;40%). We undertook analyses to explore the heterogeneity of treatment effects using meta-classification (MC) algorithms followed by propensity score matching and inverse-probability-of-treatment weighting (IPTW) from a landmark of 24 hours from hospitalization. Results Of 1,250 NSTE-ACS first-day survivors with diabetes (median age 67 years; 59%, men), 470 (37.6%) received early PCI and 780 routine medical treatment. The overall 30-day all-cause mortality rates were higher in the routine medical treatment than the early PCI group (6.3% vs. 2.5%). The prediction results of the MC algorithms accounted for only one interaction term that was statistically significant: age ≥65 years. After propensity-matched analysis as well as IPTW, early PCI was associated with reduced 30-day all-cause mortality in the older age (OR: 0.35; 95% CI: 0.14 to 0.92 and 0.43; 95% CI: 0.21 to 0.86, respectively), whereas younger age had no association with the primary endpoint. Similar results were also obtained for the secondary endpoint. Conclusions Among patients with diabetes hospitalized for NSTE-ACS, an early, within 24 hours, PCI strategy is associated with reduced odds of 30-day mortality only for patients aged 65 years or over. MC algorithms provide accurate identification of treatment effect modifiers.

P5750Manipulation strategy for crossing coronary chronic total occlusion: an update from the Japanese CTO-PCI expert registry

Abstract Background The percutaneous coronary intervention (PCI) strategy for chronic total occlusion (CTO) based on the guidewire manipulation time remains infrequent. Purpose We aimed to assess CTO-PCI strategy on the basis of guidewire manipulation time. Methods A total of 5843 patients undergoing CTO PCI between January 2014 and December 2017 and enrolled in the Japanese CTO-PCI expert registry were assessed. Their CTO-PCI strategies, procedural outcomes, and guidewire manipulation time were analysed. Results The primary retrograde approach was performed on 1562 patients (26.7%). The overall guidewire and technical success rates were 92.8% and 90.6%, respectively. Median guidewire manipulation time of guidewire success and failure were 56 (interquatile range [IQR]: 22 to 111) min and 176 (IQR: 130 to 229) min, respectively. The average Japanese CTO score of the primary antegrade approach with the antegrade alone, the primary antegrade approach with the retrograde approach, and the primary retrograde approach were 1.7±1.1, 2.1±1.2, and 2.3±1.1, respectively (p&lt;0.001). Median successful guidewire crossing time of single wiring in the antegrade alone was 23 (IQR: 11 to 44) min, and that of the primary retrograde approach was significantly shorter than that of the primary antegrade approach with the retrograde approach (107 [IQR: 70 to 161] min vs. 126 [IQR: 87 to 174] min; p&lt;0.001). Reattempt, CTO length ≥20 mm, and proximal cap ambiguity were the predictors of guidewire failure in the primary antegrade approach with antegrade alone, but were not those in the primary retrograde approach. Conclusions Although successful guidewire crossing time of the primary antegrade approach with the antegrade alone is short, that of the primary retrograde approach can be shorter than that of the primary antegrade approach with the retrograde approach. Choosing an appropriate CTO-PCI strategy leads to shortening of successful guidewire crossing time.

1155Prognostic impact of SYNTAX Score in patients with myocardial infarction with multivessel coronary artery disease and cardiogenic shock: insight from the CULPRIT-SHOCK Trial

Abstract Background The majority of patients presenting with myocardial infarction (MI) and cardiogenic shock (CS) have multivessel coronary artery disease. The prognosis impact of the SYNTAX score (SS) in this setting remains unknown. Purpose To evaluate the prognosis value of the SS in this high-risk population undergoing percutaneous coronary intervention (PCI) Methods The CULPRIT-SHOCK trial was an international, open-label trial, where patients presenting with MI and multivessel disease complicated by CS were randomized to a culprit-lesion-only or an immediate multivessel PCI strategy. Pre-PCI SS was assessed by a central core laboratory and patients were categorized as low SS (SS ≤22), intermediate SS (22&lt;SS≤32) and high SS (SS&gt;32). Adjudicated endpoints of interest were the risks of all-cause death or renal replacement therapy at 30 days and all-cause death at 1 year. Associations between SYNTAX score and outcomes were assessed using multivariate logistic regression. Results SS was available in 632 patients, of whom 265 (41.9%), 211 (33.4%) and 156 (24.7%) presented with low, intermediate and high SS, respectively. Patients with higher SS were older, with more frequent peripheral artery disease, less current smoking, lower creatinine clearance, and higher use of catecholamine. A stepwise increase in the incidence of adverse events transitioning from low to intermediate and high SS was observed with the 30-day risk of death or renal replacement therapy as well as the 1-year risk of all-cause death (p for trend &lt;0.001, for all). After multiple adjustment, intermediate and high SS remained strongly associated with 30-day risk of death and renal replacement therapy and 1-year risk of all-cause death (Figure). There was no significant interaction between SYNTAX score and the coronary revascularization strategy for all endpoints. Conclusion In patients presenting with acute MI, multivessel disease and CS, the SYNTAX score was strongly associated to 30-day and 1-year mortality&lt;/ss≤&lt;ss≤32)&gt; Acknowledgement/Funding The CULPRIT-SHOCK trial was Supported by a grant agreement (602202) from the European Union Seventh Framework Program and by the German Heart Research

P1719Sex-specific PCI strategies in patients with AMI and cardiogenic shock: a substudy of the culprit-shock trial

Abstract Background and purpose Women are more likely to suffer from a cardiogenic shock (CS) as the most severe complication of an acute myocardial infarction (AMI) and tend to have a higher mortality. Data concerning optimal management among women with CS are lacking. Aim of this study was therefore to better define characteristics of women suffering a CS and to investigate the influence of sex on different coronary revascularisation strategies Methods and results In the CULPRIT-SHOCK trial, patients with CS complicating AMI and multivessel coronary artery disease were randomly assigned to one of the following coronary revascularisation strategies: either percutaneous coronary intervention (PCI) of the culprit lesion only or immediate multivessel PCI. Primary end-point was a composite of death from any cause or severe renal failure leading to renal-replacement within 30 days after randomisation. We investigated sex-specific differences in general and according to the revascularisation strategies. Among all 706 randomised patients 26% were women. After 30 days, the primary end-point occurred in 55% women and 49% men (p=0.20), showing a relative risk of 1.14; 95% CI 0.94–1.38; p=0.17, women vs. men. Those women were older, more frequent diabetic and had more peripheral artery disease and less frequent smokers and less often family history of coronary artery disease. Regarding revascularisation strategy the composite end-point occurred in 55.8% women treated with the culprit-only strategy (vs. 42.4% men, p=0.04) and in 54.7% women in the multivessel group (vs. 55.6% men, p=0.99). This resulted in a no-significant difference among both groups (interaction p-value of 0.11). Conclusions In this large randomised trial among patients with multivessel coronary disease and CS complicating AMI, women had similar outcome for mortality and severe renal failure. Sex did not show to influence mortality and renal failure according to the different coronary revascularisation strategies. These data suggest that women and men presenting with CS should be treated equally.

Prediction of side branch occlusions in percutaneous coronary interventions by coronary computed tomography: the CT bifurcation score as a novel tool for predicting intraprocedural side branch occlusion.

Side branch (SB) occlusion is one of the major technical hurdles in the percutaneous coronary intervention (PCI) of bifurcation lesions. Our aim was to investigate whether preprocedural coronary computed tomography angiography (CCTA) could predict intraprocedural SB occlusion. A total of 260 bifurcation lesions were enrolled from 246 patients who underwent CCTA before elective bifurcation PCI. Quantitative plaque analysis was performed in the main vessel (MV) and SB. Intraprocedural SB occlusion occurred in 42 lesions (16%). These lesions were characterised by SB plaque, calcified plaque in the MV, low attenuation plaque in the main proximal segment or SB, and a ratio of MV to SB ostium area >4.3, which constituted a point-based CT bifurcation score. The CT bifurcation score was cross-validated, outperforming any angiographic Medina classification or RESOLVE score (c-statistics=0.749 versus 0.631 to 0.551; p<0.05 for all). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the CT bifurcation score ≥1 were 90%, 42%, 23%, 96%, and 50%, respectively. Comprehensive CCTA assessment was able to predict intraprocedural SB occlusion better than the current angiographic classification or scoring system. The CT bifurcation score may thus be a helpful guide for selecting the optimal bifurcation PCI strategy.

Single Long Stents versus Overlapping Multiple Stents in the Management of Very Long Coronary Lesions: Comparisons of Procedures and Clinical Outcomes

Background: Different percutaneous coronary intervention (PCI) strategies, including the use of single long stents (SLSs) and overlapping multiple stents (OMSs), have been introduced to treat very long coronary lesions (VLCLs). The aim of this study was to compare procedural and long-term clinical outcomes between SLSs and OMSs in patients with VLCLs. Methods: In this historical cohort study, 1709 patients who underwent PCI with the new generation of drug-eluting stents (length ≥38 mm) were stratified into the SLS [PROMUS /Resolute/XIENCE (PRX), (=38 mm), n=1121 (65.59%) and BioMime, (≥40 mm), n=124 (7.26%)] and OMS [(59.43±10.80 mm), n=464 (27.2%)] groups and followed up for 440.93±361.32 days. The study endpoints comprised immediate post-PCI outcomes, major adverse cardiovascular events (MACE), the patient-oriented composite endpoint (POCE), and the device-oriented composite endpoint (DOCE) at the long-term follow-up. Results: The mean age of the patients was 59.28±10.60 years, and 69.6% of them were male. Flow grade 3 (P=0.296) and residual stenosis (P=0.533) were statistically similar between all the groups. A lower level of post-PCI troponin was observed in the BioMime group [14.52 (IQR25%-75%:10.44-22.42) ng/L; P=0.031] than in the PRX and OMS groups [18.63 (IQR25%-75%:10.51-34.02) ng/L and 18.96 (IQR25%-75%:11.17-35.34) ng/L; respectively]. Similarly, the PRX and BioMime groups received lower amounts of the contrast agent [206.29±49.15 mL and 208.06±55.23 mL; respectively] than did the OMS group [265.50±74.69 mL; P<0.001]. There were no statistically significant differences in the incidence of MACE [81 (7.2%), 7 (5.6%), and 28 (6.0%); P=0.603], the POCE [141 (12.6%), 13 (10.5%), and 54 (11.6%); P=0.731], and the DOCE [51 (4.5%), 4 (3.2%), and 21 (4.5%); P=0.791] between the PRX, BioMime, and OMS groups, respectively. Conclusion: In the treatment of VLCLs, the SLS and OMSs appear to have similar clinical outcomes. BioMime ultra-long stents may have comparable results to PRX coronary stents.

Utilization of an Optimized Radiation Strategy in Primary Percutaneous Coronary Intervention for Patients with ST-Segment-Elevation Myocardial Infarction.

Background Recent reports about radiation risk gradually raised the safety concerns for interventional therapy. However, limited data exist on the optimized radiation strategy in primary percutaneous coronary intervention (P-PCI) for patients with ST-segment-elevation myocardial infarction (STEMI). Methods A total of 214 STEMI patients undergoing P-PCI were retrospectively analyzed. Patients were divided into the optimized radiation strategy (ORS) group (N = 151) and normal radiation strategy (NRS) group (N = 63) according to the radiation protocol utilized. The primary endpoint was the relative dose reduction of total air kerma. The secondary endpoint was 30-day major adverse cardiac and cerebrovascular events (MACCE), as a composite of all-cause death, reinfarction, ischemia-driven target vessel revascularization, and stroke. Results Patient groups were well matched for baseline characteristics. There were no differences in terms of age, body mass index, radial artery access, nonculprit vessel PCI, and fluoroscopy time between 2 groups. With optimized radiation strategy, a 40.9% radiation dose reduction (901.2 ± 628.7 mGy versus 1524.0 ± 866.6 mGy, p < 0.001) was obtained for total air kerma. No significant differences were found for 30-day MACCE between 2 groups (2.0% versus 1.6%, adjusted hazard ratio: 0.7, 95% confidence interval: 0.1 to 8.6, p=0.772). Conclusion With optimized radiation strategy, significant radiation dose reduction could be achieved in P-PCI for STEMI patients. It appears to be feasible and safe to carry out the optimized radiation strategy in P-PCI for STEMI patients.

A simplified formula to calculate fractional flow reserve in sequential lesions circumventing the measurement of coronary wedge pressure: The APIS-S pilot study.

A simplified formula to calculate the predicted fractional flow reserve (FFR) in sequen-tial coronary stenosis without balloon inflation is hereby proposed. In patients with an indication for FFR and sequential coronary stenosis, FFR was recorded distally and between the lesions. The predicted FFR for each stenosis was calculated with a novel formu-la. While treating one of the lesions, wedge pressure was measured during balloon inflation to calculate Pijls' formula. FFR of the remaining lesion was finally recorded (measured FFR). Forty patients were enrolled in the study, 4 (10.0%) had a distal FFR > 0.80 and were excluded from the main analysis. In the remaining 36 patients, the novel formula and Pijls' formula showed virtually absolute agreement (ICCa 0.999, R2 = 0.997 for the proximal lesion, R2 = 0.999 for the distal lesion, kappa 1.000, Se 100%, Sp 100%). The agreement between predicted and measured FFR was good (ICCa 0.820; 0.640-0.909, R2 = 0.717, intercept = 0.05, slope = 0.92, kappa 0.748, Se 75%, Sp 96%). In 19 (47.5%) cases the use of the formula enabled the operator to freely decide which lesion should be treated first, an option not available if the percutaneous coronary intervention (PCI) were guided by the largest pressure drop across each lesion. The predicted FFR for each lesion in sequential coronary stenosis can be accurately calculated by a simplified formula circumventing the need for balloon inflation. This approach provides the operator upfront, with detailed information on physiology, thus having a potentially high impact on the corresponding PCI strategy.